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PENGKAJIAN KEPERAWATAN INTENSIF

Tgl/Jam : No. RM :
Ruangan : Diagnosa Medis :

IDENTITAS
Nama / Inisial : Jenis Kelamin :
Umur : Status Perkawinan :
Agama : Sumber Informasi :
Pendidikan : Hubungan :
Pekerjaan :
Suku/Bangsa :
Alamat :
RIWAYAT SAKIT DAN KESEHATAN
Keluhan utama saat MRS :
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Keluhan utama saat pengkajian :
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Riwayat Penyakit saat ini :
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Riwayat Alergi :
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Riwayat Pengobatan :
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BREATHING
Jalan Nafas : Paten Tidak Paten
Obstruksi : Lidah Cairan Benda Asing Tidak Ada
Muntahan Darah Oedema Tidak Ada
Suara Nafas : Snoring Gurgling Stidor Tidak Ada
Nafas : Spontan Tidak Spontan
Geraka dinding dada : Simetris Asimetris
Irama Nafas : Cepat Dangkal Normal
Pola Nafas : Teratu Tidak teratur
Jenis : Dispnoe Kusmaul Cyene Stoke Lain..........
Suara Nafas : Vesikuler Stidor Whezzing Ronchi
Sesak Nafas : Ada Tidak Ada
Cuping hidung: Ada Tidak Ada
Retraksi otot bantu nafas : Ada Tidak Ada
Pernafasan : Pernafasan dada Pernafasan Perut
Batuk : Ya Tidak Ada
Sputum : Ya, Warna: ................. Konsistensi:............... Volume:......... Bau:........
Tidak
RR : .............x/menit
Alat bantu nafas : OTT ETT Trakeostomi
Ventilator, Keterangan : ..................
Oksigenasi : ..........lt/menit Nasal Kanul Simpel mask Non RBT mask
RBT mask Tidak Ada
Lain : ................................
Masalah Keperawatan :
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BLOOD
Nadi : Teraba Tidak Teraba N : ................x/menit
Tekanan Darah : ........................mmHg
Pucat : Ya Tidak
Sianosis : Ya Tidak
CRT : <2 detik >2 detik
Akral : Hangat Dingin
Pendarahan : Ya, Lokasi ...................... Jumlah ..............cc Tidak
Turgor : Elastis Lambat
Diaphoresis : Ya Tidak
Riwayat kehilangan cairan berlebih : Diare Muntah Luka Bakar
IVDF : Ya Tidak, Jenis cairan ..................................
Lain : ..................
Masalah Keperawatan :
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BRAIN
Kesadaran : Compos mentis Delirum Somnolen Apatis Koma
GCS : Eye ........ Verbal ....... Motorik ........
Pupil : Isokor Unisokor Pinpoint Medriasis
Refleks Cahaya : Ada Tidak Ada
Reflek Fisiologis : Patela (+/-) Lain – lain ..............
Refleks Patologis : Babinzky (+/-) Kerning (+/-) Lain – lain ...................
Refleks Bayi : Refleksi Rooting (+/-) Refleksi Moro (+/-)
(Khusus PICU/NICU) : Refleksi sucking (+/-)
Bicara : Lancar Cepat Lambat
Tidur Malam : ....................... jam Tidur siang : ......................jam
Ansietas : Ada Tidak Ada
Lain : .............
Masalah Keperawatan :
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BLADDER
Nyeri pinggang : Ada Tidak Ada
BAK : Lancar Inkontinensia Anuri
Nyeri BAK : Ada Tidak Ada
Frekuensi BAK : ........................... Warna : ........................ Darah : Ada Tidak Ada
Kateter : Ada Tidak ada, Urine output : ....................
Lain : ........................
Masalah Keperawatan :
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BOWEL
TB : .............cm BB : .............Kg
Nafsu makan : Baik Menurun
Keluhan : Mual Muntah Sulit menelan
Makan : Frekuensi ...............x/hari Jumlah .................Porsi
Minum : Frekuensi ...............gls/hari Jumlah ...............cc/hari
Perut Kembung : Ya Tidak
BAB : Teratur Tidak
Frekuensi BAB : ....... x/hari Konsistensi : ............. Warna : .......... darah (+/-) / lender (+/-)
Lain : ..............
Masalah Keperawatan :
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BONE
Nyeri : Ada Tidak
Problem : ............................................ Qualitas/ Quantitas : ................................
Regio : ............................................ Skala : ................................
Timing : ............................................
Kekuatan Otot : ............................................
Deformitas : Ya Tidak Lokal ........................
Contusio : Ya Tidak Lokal ........................
Abrasi : Ya Tidak Lokal ........................
Penetrasi : Ya Tidak Lokal ........................
Edema : Ya Tidak Lokal ........................
Luka Bakar : Ya Tidak Lokal ........................
Grade : ......................%

Jika ada luka / vulnus, kaji :


Luas Luka : .................................
Warna dasar luka : .................................
Kedalaman : .................................

Aktivitas dan latihan : 0 1 2 3 4


Keterangan :
Makan / minum : 0 1 2 3 4
Mandi : 0 1 2 3 4 0 : Mandiri
1 : Alat bantu
Toileting : 0 1 2 3 4 2 : Dibantu orang lain
Berpakaian : 0 1 2 3 4 3 : Dibantu orang lain dan alat
4 : Tergantungan total
Mobilisasi di tempat tidur : 0 1 2 3 4
Berpindah : 0 1 2 3 4
Ambulasi : 0 1 2 3 4
Masalah Keperawatan :
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HEAD TO TOE
(Fokus pemeriksaan pada daerah trauma / sesuai kasus non trauma )
Kepala dan wajah :
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Leher :
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Dada :
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Abdomen dan Pinggang :
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Pelvis dan Perineum :
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Ekstremitas :
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Masalah Keperawatan :
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TEST DIAGNOSTIK DAN TERAPI MEDIS


Hasil laboratorium (TGL) : ......................................................................
Terapi medis saat ini (TGL) : ......................................................

Masalah Keperawatan :
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ANALISA DATA DAN DIAGNOSA KEPERAWATAN INTENSIF

Nama Klien : No. RM :


Umur / JK : Dx. Medis :
No Data Interpretasi Masalah Diagnosa
Keperawatan Keperawatan
No Data Interpretasi Masalah Diagnosa
Keperawatan Keperawatan
DIAGNOSA KEPERAWATAN

No Diagnosa Keperawatan
RENCANA TINDAKAN KEPERAWATAN

Hari, No. Rencana Keperawatan


Tanggal Dx Tujuan dan Kriteria Hasil Intervensi
Hari, No. Rencana Keperawatan
Tanggal Dx Tujuan dan Kriteria Hasil Intervensi
TINDAKAN KEPERAWATAN INTENSIF

Nama : No.RM :
Umur / JK : Diagnosa Medis :
Ruangan :

No Tgl / Jam No. Implementasi Evaluasi Paraf


Dx
No Tgl / Jam No. Implementasi Evaluasi Paraf
Dx
EVALUASI KEPERAWATAN INTENSIF

Nama : No.RM :
Umur / JK : Diagnosa Medis :
Ruangan :
No.
No Tgl / Jam Evaluasi Paraf
Dx
No Tgl / Jam No. Evaluasi Paraf
Dx

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